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Gill Heart Institute Strive to Revive Case Study 1.

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Presentation on theme: "Gill Heart Institute Strive to Revive Case Study 1."— Presentation transcript:

1 Gill Heart Institute Strive to Revive Case Study 1

2 Case Objectives Discuss critical aspects of initial resuscitation that affected outcomes Discuss important aspects of post- resuscitation care: –ECMO –Management of VT

3 CASE DETAILS CC: unconscious during MVA HPI: 58 yo female w/ PMHx notable for obesity s/p gastric bypass surgery, DM, HTN, hypothyroidism who presented as a trauma alert after a MVA. Patient reportedly had swerved off the road and slowed to a stop with minimal trauma. Bystanders noted that patient was unconscious, and called EMS.

4 EMS called – found patient to be pulseless. CPR initiated. Primary rhythm was PEA, and was given epinephrine and chest compression –Regained Pulse in the field and was found to be tachycardic Patient was transferred to OSH Pre-Hospitalization OSH CourseED Course Early Hospitalization and Workup Rest of Hospitalization

5 At OSH, patient was intubated for airway protection and hypoxic respiratory failure Found to be in Atrial Fibrillation with Rapid ventricular response –Loaded on Amiodarone at OSH Transferred to UK as a Trauma Alert Pre- Hospitalization CPR initiated Regained pulse OSH Course ED Course Early Hospitalization and Workup Rest of Hospitalization

6 HISTORY PMHx: –HTN –Hypothyroidism –DM –OA –Obesity PSurgHx: –s/p Gastric Bypass Surgery >10 years ago –Hernia repair –Total Knee replacement FamHx: –No history of SCD or ICD placement. Detailed family history unavailable SocHx: –Significant EtOH abuse per family that was present. –No known illicit drug use. –Significant social stressors – Recent death of husband and premature birth of grandchildren – ROS: –Not obtainable

7 HISTORY Medications: –Levothyroxine 200 mcg daily –Lisinopril 10 mg daily –Metformin 500 mg twice daily –Metoprolol Succinate 25 mg daily Allergies: No known drug or food allergies

8 PHYSICAL EXAM Vitals: HR: 169, BP: 97/63, RR: 39, SpO2 of 99% on 100% FiO2 Gen: Obese, mechanically ventilated, cool to touch Head: Atraumatic, plethoric and cool Eyes: Left pupil is 5 mm and right is 3 mm, reactive Nose: Nares patent, no discharge Mouth: Endotracheal tube in place Neck: Trachea midline Respiratory: Distant breath sounds CV: Irregularly irregular, tachycardic, 1+ central pulses Abdomen: Soft nontender distended Extremities: Cool, absent distal pulses Neuro: She is intermittently flexing upper extremities with no purposeful movement, no response to pain Psych: Unable to assess

9 Initial ECG

10 Afib with RVR to the 170s Concern that patient had inadequate perfusion with SBP<100 DCCV at 200 J x 1 with conversion to sinus rhythm transiently then return to Afib with RVR Trauma called – no significant trauma noted Pre- Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Early Hospitalization and Workup Rest of Hospitalization

11 Work-up –CT PE – negative –CT head and spine – no significant acute findings other than rib fractures Thought to be related to CPR Cardiology consulted for evaluation Pre- Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Early Hospitalization and Workup Rest of Hospitalization

12 Patient went emergently to cardiac cath lab given cardiovascular arrest and subsequent arrhythmia –RHC RA: 26 mmHg PA: 52/24, mean of 38 mmHg PCWP: 30 mmHg PA saturation: 24% –CO, CI: 3.8 L/min, 1.9 L/min/m2 –Selective coronary angiography Non-obstructive CAD –Left ventriculography Global Hypokinesis w/ EF<30% –Left Heart catheterization LVEDP: 30 mmHg Pre- Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Given Diltiazem 10 mg x 1 Followed by DCCV Early Hospitalization and Workup Rest of Hospitalization

13 Given inotropes in the cath lab, with minimal improvement Placed emergently on VA ECMO Transferred to the CVICU under the care of the CCU team Pre- Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Given Diltiazem 10 mg x 1 Followed by DCCV Early Hospitalization and Workup Rest of Hospitalization

14 Telemetry strips in CCU

15

16 Polymorphic ventricular tachycardia noted soon after arrival to the CCU Defibrillated X 1 with return of sinus rhythm Pre- Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course DCCV Early Hospitalization and Workup Rest of Hospitalization

17 First ECG after Defibrillation

18 Initial Labs: –CBC unremarkable –Na: 138 –K: 6.3 –Cl: 106 –CO2: 11 –BUN/Cr: 14/1.14 –Mag: 1.3 –Ca: 7.9 –Phos: 6.1 ABG: –pH: 7.32 –PaCO2: 22 –PaO2: 291 –Base Deficit: 13 –Albumin 2.3 –AG: 21 –TnI: 0.29 Pre- Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Given Diltiazem 10 mg x 1 Followed by DCCV Early Hospitalization and Workup Rest of Hospitalization

19 Initial Labs: –CBC unremarkable –Na: 138 –K: 6.3 –Cl: 106 –CO2: 11 –BUN/Cr: 14/1.14 –Mag: 1.3 –Ca: 7.9 –Phos: 6.1 ABG: –pH: 7.32 –PaCO2: 22 –PaO2: 291 –Base Deficit: 13 –Albumin:2.3 –AG: 21 –TnI: 0.29 Pre- Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Given Diltiazem 10 mg x 1 Followed by DCCV Early Hospitalization and Workup Rest of Hospitalization

20 Initial assessment Cardiogenic shock with new global LV dysfunction –Etiology non-ischemic EtOH vs other non-ischemic etiology Stunning from either CPR or initial arrest –Afib w/ RVR secondary to this? AG metabolic acidosis w/ respiratory compensation Profound hyperkalemia and hypomagnesemia QT prolongation –Mg and QT prolonging agents

21 Was initially on dopamine, but went into polymorphic VT –Magnesium aggressively repleted –Amiodarone and other QT prolonging agents had been stopped –Started on isoproterenol to increase basal heart rate and decrease opportunity for myocytes to spontaneously depolarize Pre-Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Given Diltiazem 10 mg x 1 Followed by DCCV Early Hospitalization and Workup Cardiac catheterization PA sat: 27% ECMO Workup – QT prolonged Mg of 1.3 Rest of Hospitalization

22 Did not require vasopressors Was cautiously diuresed –Close monitoring of electrolytes Added afterload reduction as a part of a CHF regimen –Lisinopril –Spironolactone –Metoprolol switched to Carvedilol Pre-Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Given Diltiazem 10 mg x 1 Followed by DCCV Early Hospitalization and Workup Cardiac catheterization PA sat: 27% ECMO Workup – QT prolonged Mg of 1.3 Rest of Hospitalization

23 Repeat ECG showed QTc of 530. Had an episode of Afib while on isoproterenol requiring DCCV No more VT after improvement in QTc and correction of Mg Weaned off ECMO with stable HD Extubated and transferred to the floor Neurologically intact Pre-Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Given Diltiazem 10 mg x 1 Followed by DCCV Early Hospitalization and Workup Cardiac catheterization PA sat: 27% ECMO Workup – QT prolonged Mg of 1.3 Rest of Hospitalization

24 Final Assessment: –Cardiogenic shock 2/2 non-ischemic CM – resolved –LV dysfunction – not resolved –Polymorphic VT – resolved –Prolonged QTc – improved, but not resolved –Respiratory failure after arrest – resolved Pre-Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Given Diltiazem 10 mg x 1 Followed by DCCV Early Hospitalization and Workup Cardiac catheterization PA sat: 27% ECMO Workup – QT prolonged Mg of 1.3 Rest of Hospitalization

25 Summary of Hospital Course Timeline Pre- Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Given Diltiazem 10 mg x 1 Followed by DCCV Early Hospitalization and Workup Cardiac catheterization PA sat: 27% ECMO Workup – QT prolonged Mg of 1.3 Rest of Hospitalization Polymorphic VT Stopped QT prolonging agents Corrected Mg Isoproterenol Extubated Neurologically intact

26 Resuscitative Measures CPR delayed until EMS arrived –Fortunately, no evidence of anoxic brain injury Role of ECMO –Needs clearly defined end point –In this case, to allow time and interventions for resolution of cardiogenic shock and VT Management of VT –Reversible causes –Important to understand etiology of VT

27 DM Questions


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